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VERRCATION OF VEMCLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): �— <br /> Address for Vehicle: S <br /> street Address ,,,-y <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin #:46�,B,f'>�37.313 ,5) Make/Model . <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: e� L Z� O3 79 3 <br /> r Address of Owner. <br /> Street AdSZ City <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each r <br /> operating day for cleaning and servicing (CalCode sections 114245 a 114247). If the use of the co,mn-�issary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to rwY y ibis <br /> office may result in permit revgcat[ nand penalties. <br /> � <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: �• <br /> Ov✓ner Name: All <br /> Site Address: e <br /> Street Address City <br /> Phone: (Z 2 17 <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> ;Eid <br /> sa as checked below: <br /> a solid waste disposal M-Itensil washing sink <br /> (2 or 3 compartments) ❑ Store frozen food icle wash facilities <br /> Preparation of foodPi of a cold water for cleaning oiiet a hand washing ❑ Store refrigerated food <br /> atore ' food/supplies./J rovide potable water veemight parking dequate electrical outlets <br /> C L Puu(-Z <br /> Signature of Commissa Owner/Operator Date <br /> HEALTH DEPARTMENT I <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County.REHS Date <br /> EHD 16^017 - 5 of 6 MFPU APPLICA-110N <br />